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Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness, by Elliot S. Valenstein

This is a lively, fascinating, and yet scholarly account of the history of the use of psychosurgery in treating mental disorders. Focused in particular on the extraordinary Walter Freeman, with whom psychosurgery is most as sociated, the book explores the rise in use of lobotomies and similar procedures through the 1950s and the decline ever since (apart from a brief flurry in the 1970s).

Valenstein, a research psychologist and the author of Brain Control (1973), writes in a lucid, even-handed way even while concluding with a strong plea for restraint in the use of untested medical interventions. The book makes compelling reading for both laypeople and scholars. However, its narrow focus on psychosurgery makes it interesting mainly as history. Paul Hymowitz, Psychiatry Dept., Cornell Univ. Medi cal Ctr., New York. Copyright 1986 Reed Business Information, Inc.

Last Resort: Psychosurgery and the Limits of Medicine (Cambridge Studies in the History of Medicine), by Jack D. Pressman

During the 1940s and 1950s, tens of thousands of Americans underwent some form of psychosurgery; that is, their brains were operated upon for the putative purpose of treating mental illness.

From today's perspective, such medical practices appear foolhardy at best, perhaps even barbaric; most commentators thus have seen in the story of lobotomy an important warning about the kinds of hazards that society will face whenever incompetent or malicious physicians are allowed to overstep the boundaries of valid medical science. Last Resort challenges the previously accepted psychosurgery story and raises new questions about what we should consider its important lessons.

Psychosurgery: Webster's Timeline History, 1942 - 2007

Webster's bibliographic and event-based timelines are comprehensive in scope, covering virtually all topics, geographic locations and people. They do so from a linguistic point of view, and in the case of this book, the focus is on "Psychosurgery," including when used in literature (e.g. all authors that might have Psychosurgery in their name).

As such, this book represents the largest compilation of timeline events associated with Psychosurgery when it is used in proper noun form. Webster's timelines cover bibliographic citations, patented inventions, as well as non-conventional and alternative meanings which capture ambiguities in usage.

Psychosurgery in Veterans Administration hospitals: Joint hearing before the Subcommittee on Health of the Committee on Labor and Public Welfare and...Ninety-third Congress, first session, by U.S. Congress, Senate, Committee on Labor and Public Welfare. Subcommittee on Health.

Psychosurgery: Report and recommendations

My Lobotomy, by Howard Dully, Charles Fleming

At twelve, Howard Dully was guilty of the same crimes as other boys his age: he was moody and messy, rambunctious with his brothers, contrary just to prove a point, and perpetually at odds with his parents. Yet somehow, this normal boy became one of the youngest people on whom Dr. Walter Freeman performed his barbaric transorbital—or ice pick—lobotomy.

Photo credit: John A Beal, PhD. Dep't. of Cellular Biology & Anatomy, Louisiana State University Health Sciences Center Shreveport. Lobotomy, www.wikipedia.org

Photo: John Kloepper, at Central States Hospital, Milledgeville GA, 22DEC06

Page updated: April 20, 2015

Psychosurgery - Use, Types and Side Effects

Prefrontal lobotomy, cingulotomy, capsulotomy
Brief history and modern use

Normal human brain, frontal
Frontal view of normal human brain.

Psychosurgery can also be referred to as neurosurgery. Eskandar MD, Cosgrove, and Rauch of the Departments of Neurosurgery and Psychiatry, Massachusetts General Hospital, Harvard Medical School, describe psychiatric neurosurgery as "the surgical ablation or disconnection of brain tissue with the intent of altering abnormal affective and behavioral states caused by mental illness." The neurosurgeon group further state, that the "surgical target may be cerebral cortex, nuclei or pathways that display either normal or abnormal physiologic activity."

Psychosurgery History and the Early Prefrontal Lobotomy

Psychosurgery's first use in modern times was reported by Burkhardt in 1891. (Cosgrove, Rauch, 2005). The most well known example of dramatic psychosurgery is that of the prefrontal lobotomy. Mashoura, Walker, and Martuza in an article entitled Psychosurgery: past, present, and future, as published in Standford Medical, state that psychosurgery has a "complex and controversial history", and that "its abuse was due in part to the early 20th century schism of psychoanalysis and biological psychiatry".

The widespread disuse of the lobotomy in the 1950s gave way to the widespread use of psychopharmacology, along with its own issues and controversies. The surgical lobotomy gave way to a "chemical lobotomy" in psychiatric hospitals, with the advent of strong typical antipsychotic drugs, that left patients largely immobolized.

Thorazine (chlorpromazine hydrochloride) was the first to be developed, but also included among typical antipsychotics are drugs such as Haldol (Haloperidol), Prolixin (fluphenazine), and others. Typical antipsychotics are also referred to as dopamine antagonists, neuroleptics, classic antipsychotics, and first generation antipsychotics. They were and are used for similar reasons as were lobotomies, to produce psychomotor slowing, emotional quieting, affective indifference, and are still in use, although atypical antipsychotics, developed around 1994, which have fewer and less intense side effects are used more frequently today.

First developed in Portugal, the prefrontal lobotomy, particularly for violent patients in mental hospitals, was rendered upon tens of thousands of patients between 1935 and 1955, including widespread use in U.S. mental institutions. NPR reports that 50,000 lobotomies were performed in the United States during this time period. Two types of lobotomies include: 1. prefrontal lobotomy and 2. transorbital lobotomy

With a prefontal lobotomy the surgeon drills holes through the patients skull to access the frontal lobes. An "improved" version of the lobotomy was developed by a doctor was the transorbital lobotomy developed by Walter Freeman. In this surgery, the surgeon goes through the eye sockets (without permanently damaging the eyes), and could perform the surgery in less than 10 minutes. In the movie One Flew Over the Cuckoo's Nest, Jack Nicolson receives a transorbital lobotomy.

As is often the case with newly developed therapeutic techniques, initial reports of results tended to be enthusiastic, downplaying complications, (including a one in four death rate) and undesirable side effects. At times, the desired effects of calming the patient were achieved, at times the patient became a "vegetable".

Side Effects of Psychosurgery, Lobotomy, and Modern Law

Permanent inability to inhibit impulses, an unnatural "tranquility" with undesirable shallowness of absence of felling, were some of the disturbing side effects of the prefrontal lobotomy. In 1951, the Soviet Union banned all such operations.

Elliot Valnestein in the book Great and Desperate Cures explains how psychosurgery in the form of the lobotomy came to be accepted. Valenstein concluded that psychiatrists needed to gain acceptance for the practice of psychiatry as a medical science, and that the use of surgery fitted well into that need during the 1930s and 1940s. Also, the lobotomy proved to be a cost-effective treatment, and was an effective way to maintain control over mental patients who were often violent and difficult to deal with.

While the lobotomy fell out of disuse with the advent of psychotropic drugs, psychosurgery has been gaining support in modified and less-invasive forms (than the lobotomy) in the treatment of some difficult to manage and intractable disorders, as discussed in the remainder of this article.

Ice Picks-surgical instruments used for the lobotomy
Ice picks such as these were often used in performing lobotomies.

Why and When Psychosurgery Was and Is Utilized

Psychosurgery in general is not commonly used, but suggested or resorted to in enough cases that it should not be considered rare. It is suggested or used as a last resort for the intractable psychotic, severe and chronic cases of OCD (Obsessive Compulsive Disorder), at times for depression, chronic anxiety, and occasionally in treating severe pain in the case of terminal illness.

Alan A. Stone, MD in Psychiatric Times states about psychosurgery, "Despite its wretched history, psychosurgery is back with a new name—neurosurgery for mental disorders."

Neurosurgeons Cosgover and Rauch (Harvard Medical and Massachusetts General Hospital), proponents of psychosurgery state, "Surgical intervention remains an important therapeutic option for disabling psychiatric disease", which they feel is "probably underutilized." Despite this, they also state concerning psychosurgery, "However, despite these modern treatment methods, many patients fail to respond adequately and remain severely disabled," after psychosurgery. (Cosgrove, Rauch, 2005).

Modern Use of Psychosurgery and Types of Disorders for Which Psychosurgery is Utilized

Various forms of psychosurgery are performed today in neurosurgical centers in general hospitals in the United States and elsewhere.

Some of the conditions for which various types of nuerosurgery is performed are,

  • Parkinson's Disease
  • Epilepsy
  • Obsessive Compulsive Disorder (OCD)
  • Obsessive neurosis
  • Intractable depression
  • Additionally, psychosurgery has been performed, not as commonly, for,

  • Schizophrenia
  • Anxiety Neurosis

  • Modern Psychosurgery Techniques

    Today, the rate of permanent damage to the brain has been substantially improved with psychosurgery in comparison to the historical use of psychosurgery procedures, and there are fewer severely detrimental side effects. However, serious side effects can still be experienced by a significant percentage of those who undertake psychosurgery today and extreme caution is in order with any psychosurgery procedures.

    Modern psychosurgery techniques include:

  • Stereotactic limbic leukotomy
  • in the form of:

  • Subcaudate tractotomy and
  • Cingulotomy
  • Two other forms of psychosurgery are:

  • Capsultomy
  • Deep Brain Stimulation

  • Subcaudate Tractotomy

    Subcaudate tractotomy was first developed in 1965 and involves interrupting the nerve fibres that connect the orbitofrontal cortex to the thalamus. It has frequently been used for non-treatable depression and OCD. Radioactive seeds are planted in the frontal lobes or radio waves are used to destroy brain tissue.

    Approximately 1,300 subcaudate tractotomies were performed in one institution in Britain, Brook Hospital, during the 1980s, with its widespread use ending in 1994, although the procedure is still performed today. Subcaudate Tractotomy is peformed more commonly in Britain than in the U.S., where the anterior cingulotomy is preferred.


    A small bundle of nerve fibers that connect the frontal lobes with the limbic system is interrupted with a precise operation.

    Consgrove and Rauch (Harvard) report concerning cingulotomy, that "although the patient may experience an immediate reduction in anxiety, there is generally a delay to the onset of beneficial effect on depression and obsessive compulsive disorder. This latency may be as long as six to twelve weeks and must be clearly explained to the patient and referring psychiatrist.

    If there has been no response to the initial cingulotomy after three to six months, then reoperation and enlargement of the cingulotomy lesion is considered." There have been over 800 cingulotomies performed at the Massachusetts General Hospital (MGH) since 1962. (2005)

    Cingulotomy is the treatment of choice in this country whereas in Europe, capsulotomy and limbic leucotomy are more prevalent. They all appear roughly equivalent therapeutically but in terms of unwanted side effects, cingulotomy appears to be the safest of all procedures currently performed. (Cosgrove, Rauch, 2005).

    Statistical effectiveness of Cingulotomy

    The results of bilateral cingulotomy in 198 patients suffering from a variety of psychiatric disorders were reported retrospectively by Ballantine et al in 1987. With a mean follow-up of 8.6 years, 62% of patients with severe affective disorder were found to have had worthwhile improvement.

    Similarly, in patients with obsessive compulsive disorder approximately 56% were found to have undergone worthwhile improvement. In 14 patients suffering from nonobsessive anxiety disorders 50% were found to be functionally well and 29% were found to have shown marked improvement. A recent retrospective study evaluating cingulotomy in 33 patients with refractory obsessive compulsive disorder demonstrated that using very strict criteria for successful outcome, at least 25 to 30% of patients benefited substantially from the procedure. [Jenike and Baer, 1991].(Cosgrove, Rauch, 2005).

    Capsulotomy - Psychosurgery Involving Drilling Small Holes in Skull

    Originally developed in Sweden, capsultomy is a surgery which involves drilling very small holes in the skull, and inserting tiny electrodes in the brain. The electrodes are heated up, which destroys the adjacent cellular structures.

    When there is little response from the first surgery, a repeat, deeper surgery is performed. The rate of resurgery is reportedly 20%. (Cosgrove, Rauch, 2005). Neurosurgery without the need to drill has been developed using a gamma knife or proton beam.

    Anterior Capsulotomy - Facts and Statistics

    In the first 116 patients operated on by Leksell, 50% of patients with obsessional neurosis and 48% of depressed patients had a "satisfactory" response. Only 20% of patients with anxiety neurosis and 14% of patients with schizophrenia showed any improvement. In this classification system, only patients who were free of symptoms or markedly improved were judged as having a satisfactory response.

    Of the patients who were rated as worse after capsulotomy, nine were schizophrenic, four were depressive and three obsessive.

    Percentages of Success and Failure with Capsulotomy Psychosurgery

    Satisfactory response to capsultomy:

  • Obsessional Neurosis - 48%
  • Anxiety Neurosis - 20%
  • Schizophrenia - 14%
  • Rated Worse After Capsultomy Psychosurgery: - 14%

    Deep Brain Stimulation
    -------Highly Experimental Neurosurgery for Chronic Depression

    Deep brain stimulation is a highly experimental neurosurgical treatment for chronic depression in which the brain is stimulated with electrical impulses.

    Although the technique has been approved for several other conditions as well, deep brain stimulation has not been approved by the Food and Drug Administration (FDA) for depression treatment and is in the early stages of research.

    Requiring brain surgery, deep brain stimulation is the most invasive form of brain stimulation treatment for depression. Deep brain stimulation works much like a pacemaker for your brain.

    Deep Brain Stimulation Risks

    Any surgical procedure carries risks including all types of brain surgery. Deep brain stimulation involves brain surgery and is an especially risky procedure posing risks within the brain from the surgery, as well as general health risks. The brain stimulation itself may cause severe side effects.

    Possible surgical complications may include:

  • Bleeding in the brain
  • Stroke
  • Infection
  • Breathing problems
  • Nausea
  • Heart problems
  • Incision scarring
  • Possible side effects of deep brain surgery after surgery include:

  • Bleeding in the brain
  • Seizure
  • Infection
  • Delirium
  • Unwanted mood changes such as mania and depression
  • Movement disorders
  • Lightheadedness
  • Insomnia
  • Dizziness
  • Device malfunction
  • Temporary tingling in the face or limbs
  • Those who have undergone deep brain stimulation to treat Parkinson's disease have reported a variety of problems, including:

  • Panic attacks
  • Mania
  • Speech difficulty
  • Movement problems
  • Increased suicidal thoughts and behavior
  • The long-term risks and side effects of deep brain stimulation for depression are not fully known.
    (Deep Brain Stimulation. MayoClinic.com). http://www.mayoclinic.com/health/deep-brain-stimulation/MY00184)

    Effectiveness of Psychosurgery on OCD Patients

    There have not been enough studies on psychosurgery to make firm conclusions. In one small study of 35 patients with OCD who underwent capsulotomy and were followed prospectively by independent psychiatrists, 16 were rated as free of symptoms and nine were much improved for an overall satisfactory result of 70%. (Cosgrove, Rauch, 2005). Side effects, however, were not considered in this report.

    In another study of about 253 severe OCD patients, about one-half experienced a 35% reduction in intensity of symptoms after surgery. ( Mindus, eta all, 1993, 1994).

  • Another summary of studies was not as optimistic, with only 30% experiencing a 35% reduction in the intensity of OCD symptoms (Mashoura, Walkerc, Martuza. 2005).
  • Unlike the more-primitive lobotomy, deaths or increased risk of suicide does not seem to commonly result from current psychosurgery techniques.
  • Bipolar Disorder: While psychosurgery has been performed for intractable bipolar disorder, it has not been effective in treating mania, notes Cho, Lee, and Chen in the published study, "Limbic leukotomy for intractable major affective disorders: a 7-year follow-up study using nine comprehensive psychiatric test evaluations".

    Conclusion on Psychosurgery and Today's Ethical Considerations

    Despite the fact that modern psychosurgery is a far cry from past days of widespread abuse of the practice in psychiatric hospitals, the use of psychosurgery for mental disorders is still far from mainstream, nor without controversy. Massachusetts General Hospital (MGH) in Boston has led the way in the U.S., with a pilot program and the leading center for psychosurgery in the country.

    Author Andrew Solomon states that MGH only performs 15 to 20 procedures per year (2011), with a vigorous pre-screening process before surgery that lasts a full year.

    Serious questions remain, though, about the program, methodologies and ethics. While MGH has been tauted as a model program, some experts question that label. In Psychiatric Times, Alan A. Stone, M.D. writes, "in my opinion, even if one accepts the practices in place at MGH, this should not be considered a model program for centers around the world." In one case of patterning after the model of MGH, widespread serious abuse of neurosurgery has been documented in China, and important ethical considerations are still unresolved.

    1. As of 2008 there was no system of institutional review from those outside of the MGH program. The only opinions were members of the hospital's own staff.

    2. Another serious issue, one that comes up frequently in psychiatric treatment is that of informed consent. Can a person with intractable OCD in a position to provide their own informed consent? Should the family decide for them?

    3. While doctors who refer patients to the MGH neurosurgery program testify that their patients have not responded to medication treatment of to cognitive-behavioral therapy (CBT), it can be very difficult to determine if patients have actually adhered to their treatment.

    4. MGH offers neurosurgery to patients as young as 18 years of age. The brain has not stopped developing, however, until the mid-20s. Is it appropriate to promote such a drastic, last-resort method whose brains are still in physical and emotional flux?

    As to the efficacy of psychosurgery, perhaps the most carefully studied patients are those who have been treated for intractable OCD with stereotactic cingulotomy. While there have been some studies indicated significant improvements in from 28% to 50% of cases, "the unblinded nature of these studies [supporting the practice of psychosurgery] and the ongoing treatment [medications and CBT postsurgery]...limit interpretation of these results."

    Psychiatry Times points to the overriding ethical question---"Do we know enough neuroscience to know that we are not doing more harm than good in the long run?” and recommends "utmost scientific caution."

    Psychosurgery References:

    1. Carson, Robert. C., Butcher, James, N., Mineka, Susan, (2000). Abnormal Psychology and Modern Life. 11th Edition. Boston: Allyn & Bacon

    2. Cho, D., Lee W. Y., Chen C. C. (2008, February). Limbic leukotomy for intractable major affective disorders: a 7-year follow-up study using nine comprehensive psychiatric test evaluations. Journal of Clinical Neuroscience. Feb;15(2):138-42. Epub 2007 Dec 18.

    3. Cosgrove, G. R., MD., FRCS(C), Rauch, S.L., MD, (May 31, 2005). Psychosurgery. Departments of Neurosurgery and Psychiatry, Massachusetts General Hospital and, Harvard Medical School, Boston, Massachusetts

    4. Deep Brain Stimulation. (July 31, 2008). Mayo Clinic. http://www.mayoclinic.com/health/deep-brain-stimulation/MY00184

    5. Eskandar, E. N., Cosgrove, G. R., Rauch, S. L. (2001). Psychiatric Neurosurgery. Departments of Neurosurgery and Psychiatry, Massachusetts General Hospital. Boston, Massachusetts. http://neurosurgery.mgh.harvard.edu/functional/Psychosurgery2001.htm

    6. Frequently Asked Questions About Lobotomies. (2005, November 16). National Public Radio (NPR). http://www.npr.org/templates/story/story.php?storyId=5014565

    7. Kartsounis, L.D. Poynton, A., Bridges. P.K., Bartlett. J.R. (1991). Brain. 1991 Dec;114 (Pt 6):2657-73. http://www.ncbi.nlm.nih.gov/pubmed/1782537

    8. Mashoura, G. A., Walkerc, E. E., Martuza, R. L. (2005). Psychosurgery: past, present, and future. Brain Research Reviews. Retrieved April 19, 2015 from Stanford Medicine. http://med.stanford.edu/dura/Articles/Psychosurgery.pdf

    9. MGH Psychiatric Neurosurgery Committee, (May 11, 2005). Massachusetts General Hospital.

    10. Neurosurgery Service, Functional and Stereotactic Surgery Center. Massachusetts General Hospital.

    11. Solomon, A. (2001). The Noonday Demon. New York: Simon & Schuster.

    12. Stone, A. A. (2008, June 1). Psychosurgery—Old and New. Psychiatric Times. http://www.psychiatrictimes.com/articles/psychosurgery%E2%80%94old-and-new

    13. Subcaudate Tractotomy. OCD-UK. Retrieved April 19, 2015. http://www.ocduk.org/subcaudate-tractotomy